20 year old with hay fever in spring through to early July

1. 20 year old with hay fever in spring through to early July • Last 3 years reports problems with throat itching and tightness, with wheezing in exposure to brazil nuts and hazelnuts. • Last 2 years urticaria on hands after peeling carrots and potatoes • Past history: atopy i.e. eczema as a baby

2. Birch and grass pollen allergy with birch associated food problems • SPT for pollens and related offending foods • Avoid offending foods • Antihistamines • ??? epinephrine (im) -only if severe symptoms • Anaphylaxis campaign • Medic Alert • No beta blockers or tricyclic antidepressants

3. Miss Susan Gripe 24yrs • Bloating after roast meals for years • Embarassing excess flatus • Vomiting after eating Italian food • Recently sweating, palpitations, headaches, light headedness and diarrhoea, onset approx 3 hours after eating crispy fried duck

4. Monosodium Glutamate -Chinese restaurant syndrome • Present in sea weed • Hydrolysed vegetable protein/E621 • Naturally in tomatoes • Constituent of parmesan and camembert cheeses • Ingredient of many prepared and processed foods e.g. sausages, stock cubes, soup, flavoured crisps, cream crackers • Reproducibility questioned

5. 19 year female student • Sitting eating a well cooked Tuna steak. • Sudden onset of abdominal cramps, profuse vomiting and diarrhoea, diffuse flushing with itching and a severe headache. • In A+E noted to be hypotensive with palpitations • Episode lasted 6 hours without sequelae.

6. Scombroid fish poisoning • Eating spoiled fish - tuna, marlin, mahi-mahi, mackeral, • Decarboxylation of histidine in the flesh by enterobacteria • Store 0-4 ºC • Toxin is heat stable - hence cooking does not destroy it. The metallic/peppery taste is probably a myth • Treatment - Antihistamines and fluids

7. Valerie Aubergine - 18 year old • Troublesome headaches/migraine • Following chocolate, certain cheeses and red wines • Complains of flushing, rhinitis and palpitations

8. Vasoactive amines Naturally occurring substances in foods and beverages - especially fermented foods. Monoamines-chocolate, stilton and gouda cheeses, and red wine. Tyramine - • high levels - camembert and cheddar cheeses, yeast extracts, chianti wine, pickled herrings, soy sauce and chicken livers. • low levels - tomatoes, bananas, figs, aubergines and red plums

9. Salad bar syndrome • Sudden onset of bronchospasm in a self service restaurant • Eaten a bread roll with butter and mixed lettuce salad.

10. Sulphite Sensitivity • Antioxidants prevents browning • Used to prevent discolouration e.g. cellophane wrapped fruit and vegetables • Includes Sulphur dioxide, Na and K sulphite, Na metabisulphite • Added to white wine to prevent bacterial growth, also sprayed on prawns • Max on processed peeled potatoes and dried fruits • ? Rare individuals get anaphylaxis

11. Typical student! • Severe episode of urticaria following a fish and chip supper smothered in Ketchup! Past history Troublesome but intermittent urticaria,- blames several foods • Rhinitis with nasal polyps confirmed at ENT clinic. • Severe episode urticaria and angioedema of the tongue associated with wheezing whilst in hospital

12. Salicylate Sensitivity • Aspirin, NSAIDs and certain foods. High amounts in:- • Dried fruits, peanuts, most apples, berry fruits • Coffee and tea • Curry powder, Worcester sauce, tomato sauce and puree

13. Reactions to food additives • MSG • Vasoactive amines • Sulphite sensitivity • Histamine containing foods • Tartrazine and other dyes - dubious association with urticaria. • Preservatives - Benzoates and parabens - rarely associated with urticaria and asthma, but parabens can cause contact eczema in pharmaceutical and cosmetic products.

14. Male student • Complains of recent onset of abdominal bloating and loose stools. • Complaining of excessive tiredness. • Can’t be bothered to cook so eats instant foods such as cereals, pasta and sandwiches!

15. Problems with Wheat • Wheat allergy -throat swelling, abdo pain • Wheat intolerance - bloating, amount important • Coeliac disease (Gluten enteropathy) antibodies to transglutaminase, previously anti-gliaden antibodies and anti-endomysial antibodies, still need a jejunal biopsy

16. 5 year old child of a postgraduate student • Recurrent sudden episodes of profuse diarrhoea. • 6 months previously a proven episode of salmonella diarrhoea treated with Augmentin.

17. Milk allergy and intolerance • Milk intolerance related to a relative or absolute deficiency of lactase • Milk allergy - use fully hydrolysed formulas • Other names artificial butter flavour, casein, caseinates, curds, lactalbumin, rennet, whey. • There may be milk present if the label indicates caramel colour or flavouring, high protein flour, margarine and natural flavouring.

18. Cash-strapped student • Packs fresh pizzas in the evening • Itching hands at work with wheezing • Previous anaesthetic reaction • Improves when not at work

19. Latex • Urticaria/angioedema -immediate hypersensitivity -SPT/RAST • Contact dermatitis -delayed hypersensitivity -Patch testing

20. Bromoderma • Consuming 8 litres of Ruby Red Squirt daily for several months • Contains brominated vegetable oil an emulsifier • Serum bromine level was 0.96mg/dL (<0.5) • Can occur from Cola ingestion and bromine containing medications eg ipatropium bromide

21. Foods naturally rich in vitamins or fortified with them •  Carotene and Chromium (picolinate) supplementshave the capacity to cause cancer. •  Carotene should be avoided particularly in smokers who have been exposed to asbestos • Vitamin C causes abdo pain, flatulence and diarrhoea • Vitamin A increases the risk of osteoporosis and foetal malformations in pregnancy

22. 19 year old on camping trip • Stung by a ?wasp on face and upper arm • Large swelling on side of face and right upper arm swelled to twice its usual size • What is the immediate management? • What investigations would you consider? • What advice would you give?

23. Venom allergy - wasp, bee and mosquito • Local versus systemic reactions Treatment • Avoidance and insect repellents (DEET) • Antihistamines • Epinephrine 0.3mg im, repeat injection if required • Hydrocortisone 100-200mg im/iv • Investigations - Specific IgE test in primary care • Desensitisation for bee and wasp • Corticosteroids can be used for large local reactions

24. Treatment of mosquito bites with cetirizine …..These results indicate that, in mosquito sensitive subjects, prophylactically administered cetirizine is an effective drug against both immediate and delayed mosquito bite symptoms Reunula et al. Clin Exp Allergy 1993:23;72-5

25. Teaching points • Generally only allergic to proteins. • Proceed to vaccinate with MMR and Influenza in primary care unless had previous anaphylaxis to egg. Khakoo and Lack, BMJ 2000;320: 929-932 James, J. Pediatr 1998;133(5):624-8 • Multiple chemical sensitivity is CFS/FMS in disguise.

26. Allergies and Pregnancy -prenatal and post natal advice • Peanut avoidance ?! - Dept of Health 1998 • Piriton in pregnancy • Atopic mothers to avoid high allergenic foods and HDM? • Breast feed until at least 4 months as gut immature until 3 months • Avoid pets in home?